The highest rates of fetal alcohol syndrome (FAS) in the world have been found in South Africa (SA) in this town targeted for prevention research. Rates of FAS were 46 and 75 per 1,000 in waves I and II of research and a preliminary rate in Wave III is 79. A high prevalence of FAS exists in other parts of SA. Prevention research has broad implications for programs in SA, the US, and developing populations. This is a multi-site, efficacy trial of a comprehensive, public health model, community-wide, FAS prevention program defined by the Institute of Medicine (IOM). It utilizes both comparative community and pre/post prevention designs with assessment via rigorous diagnosis of FAS in children and infants and also change in measures from a random sample drinking practices survey. Rigorous program evaluation will also assess specific indicated, selected, and universal prevention techniques applied by indigenous workers. The prevention site (urban and rural components) is matched with four comparison communities which will be analyzed in aggregate and as distinct entities to assess confounding influences. Utilizing lOM-recommended techniques of research and prevention applied previously in American Indian communities, this study will determine the efficacy of community-wide prevention of FAS in SA, and which specific components are most viable. Nested studies within the prevention design also address basic research for further specificity of epidemiologic and clinical characteristics of: FAS, adult drinking, and maternal risk factors for FAS. Specific aims are to: 1.) assess the efficacy of the IOM, FAS prevention program; 2.) directly measure the prevention efficacy of the epidemiology "research only" phase via change in age-specific FAS rates; 3.) measure change in adult knowledge, attitudes, beliefs, and drinking behavior (KABB) as well as community readiness for change; 4.) link the level of participation in prevention activities to specific outcomes through process evaluation; 5.) further define maternal risk factors for FAS; and 6.) explore basic issues of risk and protection via nested studies. An extensive multivariate data analysis plan is provided for each aim. Prevention is implemented by: seven on-site prevention personnel, University of Cape Town-based staff, and U.S. and SA investigators/trainers. In indicated prevention, maternal risk is reduced via: case management of high risk individuals, access to birth control, and enhanced nutrition; brief interventions using principles of motivational interviewing and community reinforcement approach; and individual empowerment/skills building. Selective and universal prevention use: screening for alcohol abuse; targeted messages to change norms and KABB; policy advocacy; and community education and dialogue.